Skin incisions final

General Overview on Skin Incisions.
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1. Skin Incisions By: Dr Muhammad Saad Iqbal Surgery Resident DHQ Teaching Hospital Sahiwal

2. DEFINATION: Surgical Incision is a cut made through the skin to facilitate an operation or precedure . It should be the aim of the surgeon to employ the type of incision considered to be the most suitable for that particular operation to be performed.

3. Skin tension lines (Langer’s lines) . These lines represent the orientation of the dermal collagen fibres and any inci-sion placed parallel to these lines results in a better scar (Figure 7.2) Anatomical structure Incisions should avoid bony prominences and crossing skin creases if possible, and take into consideration underlying structures, such as nerves and vessels. Cosmetic factors Any incision should be made bearing in mind the ultimate cosmetic result, especially in exposed parts of the body, as an incision is the only part of the operation the patient sees. Adequate access for the procedure . The incision must be functionally effective for the procedure in hand because any compromise purely on cosmetic grounds may render the operation ineffective or even dangerous. Principles of incision

4. Skin incisions should be made with a scalpel, with the blade being pressed firmly down at right angles to the skin and then drawn gently across the skin in the desired direction to create a clean incision, the site and extent of which should have been clearly planned by the surgeon. It is important not to incise the skin obliquely because such a shearing mechanism can lead necrosis of the undercut edge. The incision is facilitated by tension being applied across the line of the incision by the fin-gers of the non-dominant hand, but the surgeon must ensure that at no time is the scalpel blade directed at their own fingers as any slip may result in a self-inflicted injury.

5. Choice of incision Depend s upon : Type of surgery [elective/emergency] Target organ Surgeons own experience and preference and Previous surgery.

6. The ideal incision allows: E ase of access to the desired structures C an be extended if needed I deally muscles should be split rather than cut H eals quickly with minimal scarring

7. Langer’s Line s Langer’s Line correspond to the natural orientation of collagen fibers in the dermis , and are generally parallel to the orientation of the underlying muscle fibers Incisions made parallel to Langer's lines may heal better and produce less scarring than those that cut across .

8. Common blades used for incisions are:

9. Abdominal & Pelvic incisions Vertical Incisions Midline Paramedian Transverse & Oblique Incisions Kocher Subcostal Incision Transverse Muscle Dividing McBurney Incisions Oblique Muscle cutting Pfannenstiel Incision Maylard Incision Abdominothoracic Incisions Retroperitoneal & extra-peritoneal approaches

10. Vertical Incisions 1)Median /Midline Incision vertical incision which follows the linea alba. It may be, upper midline incision; lower midline incision single incision. SIGNIFICANCE-it is favored In diagnostic laparotomy, as it allows wide access to abdominal Cavity.

11. Advanta g e s : A lmost bloodless N o muscle fibers are divided N o nerves are injured G ood access to upper abdominal viscera V ery quick to make as well as to close C an be extended to full lenght of abdomen curving around umblical scar. Disadvantages Care needs to be taken just above the umbilicus where the falciform ligament is attached Midline scar Bladder injury

12. Upper midline incision From xiphoid to above umbilicus. Division of the peritoneum is best performed at the lower end of the incision,just above the umbilicus ,so that the falciform ligament can be seen and avoided

13. Lower midline incision From the umbilicus superiorly to the pubis symphysis inferiorly Allow access to pelvic organs T he peritoneum should be opened in the uppermost area to avoid injury to the bladder

14. Full midline incision  From xiphoid to pubis sy m physis

15. Paramedian Incisions P laced 2 to 5 cm lateral to midline over median aspect of bulging transverse convexity of rectus muscle.

16. Advantages Provides access to lateral structures Avoids injury to nerves,limits trauma to rectus muscle. Permits good restoration of abdominal wall function Can be extended by slanting the upper end of the incision medially towards the xiphoid process if required Disadvantages Time consuming. Incision needs to be closed in layers Difficult extension superiorly as limited by the costal margin Tends to strip the muscles of their lateral blood and nerve supply resulting in atrophy of the muscle medial to the incision

17. Transverse Incisions Advantages better cosmetically Stronger than vertical Less painful Good access to upper GI structures More advantageous in children b/c of more transverse length of abdomen. Disadvantages Limited exposure to the organs

18. 1)Kocher 2)Median 3)McBurny 4)Battle 5)Ianz 6 ) P aram e dian 7)Transverse 8)Rutherford Morrison 9)Pfannensteil

19. Kocher Subcostal Incision It affords excellent exposure to gall bladder and biliary tract and can be made on left side to afford access to spleen. İs started at midline ,2 to 5 cm below the xiphoid,and extends downward s , outwards and parallel to and about 2.5 cm below costal margin Especially used in cholecystectomy

20. Chevron (rooftop) modification The incision may be continued across the midline into double kocher’s incision or rooftop appearance which provide excellent access to upper abdomen particularly in those with broad costal margin Uses- total gastrectomy total oesophagectomy extensive hepatic resection bilateral adrenectomy

21. Mercedes benz modification Consists of bilateral low kocher’s incision with upper midline incision upto the xiphisternum. Provides excellent access to the upper abdominal viscera mainly the diaphragmatic hiatuses

22. Transverse Muscle dividing In newborn and infants, this incision is preferred Because infants’ abdomen is longer transverse ly than vertica lly Also true of short, obese adult

23. McBurney grid iron(muscle splitting)incision İncision of choice in most appendicectomies The level and lenght of incision will vary according to thickness of abd. wall and suspected position of apendix.

24. It is made at the junction of middle third and outer third of a line running from umblicus to anterior superior iliac spine ( McBurney ’s point ) . Originally placed the incision obliquely from above laterally to below medially. Also used in left lower quadrant to deal with certain lesion of sigmoid colon such as drainage of diverticular abscess.

25. Lanz incision It is a variation of McBurneys incision that is made the same point but in transverse plane. It gives cosmetically better scar

26. Rutherford-Morrison Incision Oblique Muscle Cutting Incision Extension of McBurney incision by division of oblique fossa Can be used for right and left sided colonic resection, caecostomy or sigmoid colostomy

27. Pfannenstiel Incision Used frequently by gynecologist and urologist for access to pelvic organ, bladder, prostate and for c- section.

28. Maylard T ransverse Muscle Cutting Incision G ives excellent exposure to pelvic organ Skin incision is placed above but parallel to traditional placement of Pfannenstiel incision

29. Inguinal incision  Done for i nguinal hernia’s T esticular cancer, cryptorchridism , hydrocele, varicocele . It is given 2 cm above and parallel to inguinal ligament. It usually extends from level of pubic tubercle to internal ring.

30. Thoracoa b dominal Incisions Either right or left Converts pleural and peritoneal cavities into one common cavity Thereby give excellent exposure

31. Right incision may be particularly useful in elective and emergency hepatic resections Left incision may be used in resection of lower end of esophagus and proximal portion of stomach. Incision is extended along line of 8th intercostal space,the space immediately distal to inferior pole of scapula.

32. Retroperit o neal approach

33. Oblique lumbar incision  It commences 1.25cm below and lateral to renal angle and passes downwad towards the anterior superior iliac spine.

34. Incisions on posterior abdominal wall

35. Complications of abdominal incision Hematoma, Stitch abscess, Wound infection Wound dehiscence Burst abdomen Fistula formation Wound pain Incisional hernia Adhesion s and its complications Unsightly scar

36. Occasionally, ‘dog ears’ remain in the corner of elliptical incisions in spite of adequate care having been taken during formation and primary closure of an elliptical wound. In these situations, it is advisable to pick up the ‘dog ear’ with a skin hook and excise it as shown below. This allows for a satisfactory cosmetic outcome.

37. Factors affecting the strength of scar Types of surgery(acute abdomen, surgery for malignancy, major surgery) Types of incision Obesity Pregnancy Straining Cough Ascites Nutrition Diabetes Immunosuppression